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Offer routine HIV testing for all, Canada’s top medical journal says

Too many of those who are infected with HIV are diagnosed late, 'sometimes very late,' Dr. Julio Montaner, director of the British Columbia Centre for Excellence in HIV/AIDS in Vancouver, and his coauthors write in this week's edition of the Canadian Medical Association Journal.
Photo: AFP/Getty Images/Files

Routine HIV testing should be offered to every sexually active person in the country and not just those known to be at risk for HIV, the nation’s premier medical journal is arguing.

In an editorial Monday in the Canadian Medical Association Journal, world-renowned HIV/AIDS scientist Dr. Julio Montaner and his coauthors say that too many of those infected with HIV are diagnosed late, “sometimes very late,” and are unaware that their bodies are harbouring the virus.

Drug cocktails known as HAART, or highly active antiretroviral therapy, can drive blood loads of HIV to undetectable levels, the authors write. “Today, a 20-year-old who receives a diagnosis of HIV and treatment with HAART can expect to live until the age of 73 years.”

But at least one-quarter of those infected at any given time are unaware they have HIV, “and more than 50 per cent receive the diagnosis after immunodeficiency is established.”

Canada has no recommendation for routine testing beyond screening pregnant women and testing the blood supply, the authors write. Testing is also focused on people known to be at risk of HIV, including those who have multiple partners, men who have sex with men and IV drug users. “Those are the groups that traditionally get offered the test anytime they show up anywhere,” Montaner, director of the British Columbia Centre for Excellence in HIV/AIDS in Vancouver, said in an interview.

But a substantial proportion of cases is being missed.

“It could be denial, it could be they don’t know, it could be that they just don’t look the part, but obviously we need to test outside the high-risk groups,” Montaner said.

Other countries, including France, which recommends screening the entire population aged 15 to 70, are embracing the notion that people who have ever been sexually active should be offered an HIV test, Montaner said.

“We’re saying, look, it’s time that Canada does something about it. It’s not good enough that the Public Health Agency of Canada reports that a quarter of the people with HIV are unknown. We need to understand that they are unknown because they don’t fit the typical risk profile.

“The message fundamentally is, if you have been sexually active within the last five decades, you need to do one HIV test. And if you remain sexually active, you should do a test once a year,” Montaner said.

Testing would be purely voluntary, he stressed. “We’re not talking about mandating anything, and people who suspect that there is some sort of near draconian, Machiavellian strategy behind this are totally ill-informed.”

Those who are HIV-positive but who don’t know it are at highest risk of spreading the virus because they’re less likely to take precautions.

They are also the patients who, “more often than not, show up in the clinic after being infected for a decade or more, sick as a dog” and less likely to benefit from treatment, Montaner said.

Several Vancouver hospitals now offer HIV screening of all medical admissions and emergency department visits. Overall, 90 per cent of those offered testing accept it, Montaner said. Screening has picked up six new “positives” for every 1,000 HIV tests.

Screening that detects anything above one HIV-positive test per 1,000 is considered cost-effective, he said.

But there could be challenges to getting the public’s buy-in: A public opinion survey prepared for the Public Health Agency of Canada by Ekos Research Associates found that, compared to cancer, heart disease, diabetes and obesity, HIV/AIDS “is not perceived to be a particularly serious disease in Canada today,” according to an executive summary.

The telephone survey of 2,000 Canadians aged 16 and older, conducted between March 1 and May 1, found that most Canadians believe HIV is “another person’s disease” and unlikely to affect them, personally. It was posted recently to a government website. A sample of this size has a margin of error of plus or minus 2.2 percent for the sample overall, 19 times out of 20.

Those attitudes need to change, Montaner said. “To say that HIV isn’t a problem when you have rising numbers of cases is really irresponsible. How many unnecessary cases of AIDS do you need to have before you actually become concerned about it?”

Infection with HIV is a life-transforming event, he said. “It transforms the way you view yourself, it limits your ability to do things professionally or otherwise. It closes a number of doors for you. It’s something that people should be very serious about.”

Even though treatments can restore near normal longevity, “my patients can tell you, they wish they never had HIV.”

Montaner co-authored the CMAJ editorial with Reka Gustafson, a medical health officer and medical director of communicable disease control at Vancouver Coastal Health and Barbara Sibbald, a CMAJ deputy editor.